Fighting Harder and Smarter Against Malaria

1. Fighting Harder and Smarter Against Malaria Dr.Bernard Nahlen Deputy US Global Malaria Coordinator University of Georgia, February 23, 2010

2. Outline • Burden of malaria • Global support for rolling back malaria • President's Malaria Initiative • Tools for malaria prevention and treatment • Success in scaling-up interventions • Early evidence of impact • Challenges and opportunities

3. Four Human Species of Malaria • Parasitic infection of red blood cells • Plasmodium falciparum • Plasmodium vivax • Plasmodium malariae • Plasmodium ovale

4. How Is Malaria Spread? • Spread by bite of infected female Anopheles mosquitoes • Night-biting mosquitoes • Indoor-biting mosquitoes

5. Global Burden (Baseline 2000 estimates) • 107 countries and territories • 3.5 billion people-- at risk • Cases: 300-500 million a year • Deaths: >1 million a year • Mostly Plasmodium falciparum • Mostly African children: • 1 dies every 30 seconds

6. Africa:almost 100% P. falciparum, high number of cases & deaths per population at risk; the most external support; lowest governmental spending on malaria Americas, Middle-East & Eurasia:dominated by P. vivax species, very few cases and deaths; high degree of governmental spending Asia:largest population at risk, both P. vivax and P. falciparum, moderate number of cases and deaths; two-thirds of funding comes from governments

8. MALARIA BURDEN GREATEST IN AFRICA, AND AMONG CHILDREN UNDER FIVE Distribution of deaths among children under age five by cause, sub-Saharan Africa, 2000-2003

9. Chronic Disease Acute Disease MALARIA Clinical Syndromes Infection During Pregnancy Non-severe Acute Febrile disease Chronic Asymptomatic Infection Placental Malaria Cerebral Malaria Anemia LBW Developmental Disorders; Transfusions; Death Infant Mortality Death

10. Burden on African Health Systems High-burden countries in sub-Saharan Africa: • Outpatient • 30-40% visits children <5 years • 25-35% visits all ages • Inpatient • 30-50% admissions children <5 years • 20-30% admissions all ages • Hospital deaths • 20-40% deaths children <5 years • 15-40% all ages

11. Economic Burden of Malaria In Africa • Estimated annual loss of growth due to malaria up to 1.3 % each year • Compounded for 15 years, the GDP level in the 15th year reduced by nearly 1/5 • Repeated bouts of malaria hinder physical and cognitive development • Reduce a child’s attendance and performance at school • Impact on labor productivity • Household income reduced

12. Goals and Targets Roll Back Malaria Partnership Launched 1998 by WHO, UNICEF, World Bank, UNDP • Goal: To halve malaria-associated mortality by 2010 and again by 2105 • Updated Goals (Global Malaria Action Plan, 2008): • To reduce global malaria cases from 2000 levels by 50% in 2010 and by 75% in 2015 • To reduce global malaria deaths from 2000 levels by 50% in 2010 and to near zero preventable deaths in 2015 • To eliminate malaria in 8-10 countries by 2015 • In the long-term, eradicate malaria world-wide • Updated Targets: Universal coverage for all populations at risk

13. Goals and Targets Abuja Summit (April 2000), by 2005 • At least 60% of malaria patients have access to effective treatment within 24 hours of onset of symptoms • At least 60% of those at risk of malaria benefit from protective measures, such as ITNs or IPT UN Millennium Development Goals • Target 8: To have halted by 2015 and begun to reverse the incidence of malaria and other major diseases • Indicator 21: Prevalence and death rate associated with malaria • Indicator 22: % of population at risk in malaria-risk areas using effective malaria prevention and treatment measures

14. Annual global costs (US$ millions)

15. Current funding required by region(US$ millions)

16. Who supports the effort to fight malaria?

17. Global Malaria Funding Initiatives Global Fund to Fight AIDS, TB and Malaria • Established July 2001 by G8 countries • To date, US$ 4.6 billion committed to support countries to fight malaria US President’s Malaria Initiative, by 2010 • Launched June 2005 • Phase 1: $1.26 billion over 5 years to fight malaria in 15 focus countries in Africa • Phase 2: $ 5 billion over 5 years (2009-2013) World Bank Malaria Booster Program • Launched September 2005 • Phase 1: $500 million to fight malaria in Africa • Phase 2: $1 billion Gates Foundation Malaria Forum (October 2007) • Goal: Elimination Eradication

18. US President’s Malaria Initiative Goal: To contribute to reduction of malaria-associated mortality by 50% Targets: To expand coverage of malaria prevention and treatment measures to 85% of the most vulnerable populations – children <5 years of age and pregnant women • Interagency initiative led by USAID, and implemented together with CDC • Interagency Steering Group • USAID • Dept of Health and Human Services • Department of State • Department of Defense • National Security Council • Office of Management and Budget

19. PMI Focus Countries • Beginning in FY06: Angola, Tanzania, Uganda • Beginning in FY07: Rwanda, Senegal, Mozambique, and Malawi • Beginning in FY08: Benin, Ghana, Mali, Kenya, Liberia, Madagascar, Zambia, Ethiopia (Oromiya Region) • Beginning in FY 2011: DR Congo and Nigeria

20. PMI Funding Levels

21. Transparency & Accountability PMI Web Site (www.fightingmalaria.gov) • Operational plans • PMI strategy and program/technical guidance • All contracts and agreements • Activity reports from Implementing Partners

22. What tools do we have to fight malaria?

23. Life-Saving Interventions 1.Long-lasting Insecticide-treated mosquito nets (LLINs) Prevent malaria transmission Provide a physical and chemical barrier against mosquito bites To be effective, must be used 2.Indoor residual spraying (IRS) Prevents malaria transmission for all members of a household 12 insecticides approved by WHO for IRS Pyrethroids and DDT most common

24. Life-Saving Interventions 3. Intermittent preventive treatment in pregnancy (IPTp) Prevents adverse effects of malaria in pregnancy: anemia in mother low birth weight for infant, major risk for newborn death Case management Dx malaria using microscopy or RDTs when available Rx uncomplicated malaria with artemisinin-based combination therapy (ACTs)

25. Intermittent preventive treatment IPT involves the administration of full, curative treatment doses of an effective antimalarial drug at predefined intervals during pregnancy

26. Benefit: Mothers less malaria less anaemia Infants fewer of LBW Intermittent Preventive Therapy Rx Rx 20 10 30 Birth Quickening Conception Weeks of pregnancy

27. Low birth weight

28. Insecticide-Treated Materials • Physical barrier • Long-acting insecticide • Repellent activity

29. ITN Efficacy Trials in AfricaEntomologic Inoculation Rates and Protective Efficacy Gambia (EIR=1-30) 23% Western Kenya (EIR=300+ {per}) 16% Burkina Faso (EIR=300-500 {sea}) 14% Ghana (EIR=100-300 {sea}) 18% Coastal Kenya (EIR=10-30) 29% Lengeler C, et al., 1999. Phillips-Howard P, et al,.2003 .

30. Household Ownership of Insecticide Treated Mosquito Nets (ITNs) in malaria-endemic African Countries 1999 - 2004 2005-2008 Mauritania Mauritania Mauritania Mauritania Niger Niger Mali Mali Niger Niger Mali Mali Eritrea Chad Chad Senegal Senegal Eritrea Chad Chad Sudan Sudan Senegal Senegal The Gambia Sudan Sudan Burkina Faso The Gambia Djibouti Guinea Bissau Burkina Faso Djibouti Guinea Guinea Guinea Bissau Benin Guinea Guinea Benin Nigeria Nigeria Sierra Leone Sierra Leone Nigeria Nigeria Ethiopia Ethiopia Sierra Leone Sierra Leone Togo Ethiopia Ethiopia Cote d'Ivoire Togo Ghana Cote d'Ivoire Ghana Liberia Liberia Central African Rep Liberia Liberia Central African Rep Cameroun Cameroun Somolia Somalia Eq Guinea Uganda Uganda Eq Guinea Zanzibar Uganda Uganda Congo, DRC Congo Zanzibar Congo Kenya Kenya Kenya Kenya Gabon Gabon Rwanda Rwanda Burundi Congo, DRC Burundi Household ownership of at least one ITN Tanzania Tanzania Tanzania Tanzania <5% Angola Angola Angola Angola Malawi Malawi Malawi Malawi Zambia Zambia Zambia Zambia 6-15% Mozambique Mozambique Mozambique Mozambique Zimbabwe Zimbabwe Zimbabwe Zimbabwe Madagascar Madagascar Madagascar Madagascar Botswana Botswana 16-30% Botswana Botswana Namibia Namibia Namibia Namibia Swaziland Swaziland 31-45% South Africa South Africa Lesotho Lesotho 46-60% >60% September 2008, data from DHS, MICS, MIS and other national surveys

31. ITNs protect pregnant women against malaria

37. Trends in inpatient and outpatient malaria cases, 2001-2006/7 Eritrea Rwanda Integrated LLIN ACT Sao Tome and Principe Zanzibar ACT LLIN IRS ACT LLIN IRS

38. Early Evidence of Impact of Nationwide Distribution of LLINs and ACTs (WHO, Global Malaria Programme, January 2008)

39. Emerging Threats Artemisinin resistance: Thai-Cambodia border Insecticide resistance

40. Research to bring forward new tools • Today’s tools today, tomorrow’s tools tomorrow • Need to continually develop improved tools and techniques and to use them wisely and widely • Resistance by the malaria parasite to today’s drugs will continue to develop; new generations of drugs will be required • Same is true for mosquitoes and the insecticides that we use against them • Vaccines against malaria are under development • over the next decades, we will see the mobilization of several generations of vaccines of different kinds

41. Challenges/Opportunities • Global • Sustaining political and financial support • Demonstrable impact within short period of time when interventions scaled up • Call for eradication/elimination • new drugs, new insecticides, vaccines, new approaches to vector control • National • Weak health systems • NMCP partnership with EPI and Reproductive Health (ANC) • Controlling malaria unburdens the health system • Implementation extends beyond MOH • NGO partners • Community • Sustaining compliance when malarial illness becomes less common

42. Are we being overly optimistic? • Consensus on package of tools • Consensus on global plan • Mechanism for partner coordination • New program partnerships (ANC, EPI, intersectoral collaboration) • Greater community involvement • Highest level political commitment • New tools being developed

43. Thank You!